The Profession of Medicine Is Secular: an Eighteenth-Century Idea with Implications for the Boundary Between Medicine and Religion

Psychiatria Danubina 2021; Vol. 33, Suppl 3, pp S292-S298 Science, Art & Religion 2021, Vol. 1, No 1-2, pp 57-63 Review article

THE PROFESSION OF MEDICINE IS SECULAR: AN EIGHTEENTH-CENTURY IDEA WITH IMPLICATIONS FOR THE BOUNDARY BETWEEN MEDICINE AND RELIGION

Laurence B. McCullough1,2 & Frank A. Chervenak1,2

1 Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA 2 Department of Obstetrics and Gynecology, Lenox Hill Hospital, New York, New York USA

SUMMARY he aim of this paper is to draw on John Gregory’s (1724-1773) professional ethics in medicine to provide guidance to physicians for the responsible management of the potentially contested boundary Tbetween medicine and religion. The paper provides a philosophical and clinical interpretation of Gregory’s method of argument by persuasion: setting out complementary considerations that together invite agreement. The cumulative effect of this argument by persuasion is that a contested boundary between medicine and religion is not required by the commitment to the evidence-based, scientific practice of medicine. Gregory’s legacy to us is the concept of the profession of medicine as secular, in two senses. As scientific, medicine draws on evidence and not on divinity, transcendent reality, or sacred texts and practices. There is no necessary hostility of evidence-based medicine toward religion and faith communities.

Key words: medicine - professional ethics- Gregory’s method – interpretations – EBM (Evidence Based Medicine)

INTRODUCTION: UBI TRES eighteenth-century response to this challenge and MEDICI, IBI DUO ATHEII. invite the reader to assess its utility for today. With the emergence of scientific medicine in Renais- JOHN GREGORY RESPONSE TO sance Europe and, especially, during the Enlighten- ment, the boundary between medicine and religion UBI TRES MEDICE, IBI DUO ATHEII. became contested. In part, this was owed to com- On the most important – but still neglected – re- peting explanations of the phenomena of health and sponses to this accusation was mounted by the Scot- disease. As the success of medical explanations and tish physician-ethicist, John Gregory (1724-1773). As clinical management based on them increased, the a young man, Gregory would have been well aware authority of religion to explain health and disease of religious persecution of atheists. In 1767 became was directly challenged. The threat of medicine to Professor of Medicine at the University of Edinburgh, religion was expressed by people of the Christian a position he held in alternating years with William faiths in the phrase, Ubi tres medici, duo atheii, or, Cullen (1710-1790). Cullen was revered as the best wherever there are three doctors there are two athe- teacher of clinical medicine at the University of Ed- ists (McCullough 1998). In this paper we present an inburgh, based on the Baconian science of rigorous

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observation of signs and symptoms and sorting them intended audience – because he devoted more words into patterns that made causal sense. Cullen was also to it than any of the many other ethical challenges he a suspected atheist. At that time, professors at the addressed (McCullough 1998). University of Edinburgh were appointed by the Town I shall make no apology for going a little out of my Council and there was no tenure. There was a move- way in treating of so serious a subject. In an enquiry ment afoot to have Cullen dismissed from his faculty into the office and duties of a physician, I deemed it position, to prevent an atheist from infecting the stu- necessary to attempt to wipe off a reflection so de- dents with heresy (McCullough 1998). rogatory to our profession; and, at the same time, to Gregory gave a series of ethics lectures before stu- caution you against that petulance and vanity in con- dents transitioned from the lecture hall to the wards versation, which may occasion imputations of bad of the Royal Infirmary of Edinburgh for their clinical principles, equally dangerous to society, and to your training. As was then common, Gregory permitted own interest and honour (Gregory 1772, p. 70). his lectures to be published anonymously, to test re- In this paper, we will explain Gregory’s response ception of them by the medical and learned commu- to the contested boundary between medicine and re- nities. Probably edited by his son, James Gregory, the ligion and show how this remarkable text from the lectures appeared in 1770 as Observations on the Du- history of medical ethics can provide reliable guid- ties and Qualifications of a Physician, and on the Method ance to the Academy today. of Prosecuting Enquiries in Philosophy (Gregory 1770). This book was very well received, leading Gregory to revise and publish it under his own name as Lectures A METHODOLOGICAL NOTE on the Duties and Qualifications of a Physician in 1772 Gregory’s style of reasoning was common in his day. (Gregory 1772). This book is remarkable for the scope It can best be described as argument by persuasion. of ethical challenges that Gregory addressed and that One sets out a number of considerations in support remain current, including confidentiality, the right of a position with the goal of persuading the reader of patients to express their views about treatment, to agree on the basis of the accumulated persuasive patients with “nervous ailments” now known as the power of all of the considerations considered togeth- “worried well,” and end-of-life care, including what er. This can also be called complementary reasoning: appears to be an endorsement of physician-assisted each successive consideration adds something not suicide (McCullough 1998). contained in its predecessor, creating a coherence Gregory addresses two contested boundaries. The among them. No one consideration, therefore, should first was between physician and surgeons. Using the be considered persuasive by itself (McCullough example of a gangrenous limb, Greogry makes the 1998). We now invite the reader to experience Grego- case for the physician taking the lead in making the ry’s method of argument by persuasion by presenting diagnosis and devising a treatment plan. If that plan in sequence each of the considerations that Gregory included surgery, the physician should turn the case advances with an update of each. over to the surgeon who then would take responsibil- ity for the surgery. No one had ever made such a proposal for the management of the contested boundary GREGORY’S ARGUMENT BY between medicine and surgery. The basis for Greg- PERSUASION ory’s proposal was the commitment of clinicians to the scientific practice of medicine directed to the pa- Scientifically Eminent Physicians of tient’s health-related interests, keeping all forms of Piety self-interest systematically secondary (Gregory 1770, 1772, McCullough 1998). Gregory first points out that there have been many The second contested boundary was that between scientifically eminent physicians who were noted for medicine and religion. Gregory almost certainly had their piety. Their examples are meant to refute Ubi in mind the political and personal peril that his col- tres medici, duo atheii, or the claim that becoming a league Cullen faced as well as the history of perse- scientific physician entails a commitment to atheism: cution of heretics. We know that this topic was of I shall conclude this subject with some observa- major importance to Gregory – and therefore for this tions on a charge of a heinous nature, which has been

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often urged against our profession; I mean that of in- It is easy, however, to see whence this calumny fidelity, and contempt of religion. I think the charge has arisen. Men whose minds have been enlarged by ill-founded; and will venture to say, that the most knowledge, who have been accustomed to think, and eminent of our faculty have been distinguished for to reason upon all subjects with a generous freedom, real piety. I shall only mention, as examples, Harvey, are not apt to become bigots to any particular sect or Sydenham, Arbuthnot, Boerhaave, Stahl, and Hoff- system. They can be steady to their own principles man (Gregory, 1772, pp. 63-64). without thinking ill of those who differ from them; His students and contemporaries would have in- but they are impatient of the authority and controul stantly recognized men who were then regarded as sci- of men, who would lord it over their consciences, and entific giants. William Harvey (1578-1657) discovered dictate to them what they are to believe (Gregory circulation. Thomas Sydenham (1624-1689) authored 1772, p. 64). a textbook in medicine that remained in use for two Gregory’s point is subtle: It is correct for the sci- centuries, earning him the sobriquet, “The English entific physician to be “impatient with the authori- Hippocrates.” Hermann Boerhaave (1668-1738) the ty and controul of men.” He may have had in mind founder of modern physiology and renowned teach- the rigid orthodoxy of the Church of Scotland and, er at the medical school at Leiden, where Gregory and as would be typical at the time, Roman Catholicism. other of “Boerhaave’s men” at the University of Edin- But it is not correct for the scientific physician to burgh studied. Georg Ernst Stahl (1659-1734) posited reject religion that is compatible with conscience. the anima to distinguish between living and non-liv- There were at the time religious communities based ing things. While this concept did not survive, the on the sovereignty of conscience, especially the var- wholistic approach to patient care, which Gregory em- ious Dissenters. Scientific medicine is therefore not braced and taught, was very influential at Edinburgh. incompatible with religion in all of its various forms Friedrich Hoffmann (1660-1742) who took the lead in but only in those forms incompatible with the sover- preparing physicians to serve as municipal physicians, eignty of conscience. forerunners of public health physicians. Hoffmann also published Medicus Politicus, a very influential text The Perils of Unguarded Expressions in the history of medical ethics (McCullough 1998). Today, there are eminent physicians noted for Scientific physicians can sometimes abandon the dis- their piety, i.e., their serious commitment to religious cipline of evidence-based reasoning and become en- beliefs and practice. The most prominent such phy- thusiasts in the sense that they make claims for which sician in the United States, and perhaps in the world, they do not have warrant. In this passage Gregory in- is Francis Collins, the Director of the National Insti- vokes the distinctive commitment of the University tutes of Health and renowned scientific investigator of Edinburgh, Lehrenfreiheit or the freedom to teach, (U.S. Public Broadcasting System (PBS) 2004, Collins which, in turn, is based on freedom of inquiry. 2006). In the PBS interview, Collins made the follow- This freedom of spirit, this moderation and char- ing claim and offered himself as an example of a sci- ity for those of different sentiments, have frequently entific physician who has a serious faith commitment: been ascribed, by narrow-minded people, to secret So where, then, is the discordancy that causes so infidelity, scepticism, or, at least, to lukewarmness many people to see these views of science and of spir- in religion; while some who were sincere Christians, it as being incompatible? In me, they both exist. They exasperated by such reproaches, have sometimes ex- both exist at the same moment in the day. They’re not pressed themselves unguardedly, and thereby afford- compartmentalized. They are entirely compatible. ed their enemies a handle to calumniate them. This, And they’re part of who I am (U.S. Public Broadcast- I imagine, has been the real source of that charge of ing System (PBS) 2004, Collins 2006). infidelity so often and so unjustly brought against physicians (Gregory 1772, pp. 64-65). Contempt for Religion does not Apply Freedom of inquiry, Gregory insists, must be rigor- to all Forms of Religion ous, in which intellectual endeavor there is no place for unguarded statements. Unguarded statements Gregory turns to the origins of contempt for religion make one a target for the accusation of infidelity, not in the scientific mind set: rigorous scientific thinking.

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Newly Won Liberty But, supposing that Atheism came universally to prevail, together with the disbelief of the immortali- Gregory then makes a related, more general point: ty of the soul, the duration of such sentiments would unbridled freedom can result in atheism: necessarily be very short; because they would at once In a neighboring nation, where few people have unhinge all the bonds of society, and produce a con- been used to think or to reason with freedom on re- tinued scene of anarchy and wickedness (Gregory ligion, and where, till of late, no man durst express 1772, p. 66). himself freely on the subject, some ingenious and These words would have had a powerful reso- lively writers have, within these few years appeared, nance for Scotsmen, who were only a quarter century who, impatient to display their newly-acquired lib- from the doomed Stuart rebellion of 1746-1747. Greg- erty, have attempted to shake the foundations of all ory had been recruited to fight by the legendary Rob religion, natural as well as revealed. Lately emanci- Roy but Gregory’s father forbade him to enlist, thus pated from the lowest superstition, by a transition saving him from the slaughter that befell the Scottish not unnatural, they have plunged at once into Athe- rebels at the battle of Culloden (McCullough 1998). ism. It is perhaps for the better, that these gentle- Gregory knew firsthand of what he writes: social men have carried matters so far; because it is to be bonds should never be taken for granted and, when hoped the evil will soon cure itself (Gregory 1772, pp. they fail, catastrophe usually follows. 65-66). Here he emphasizes that unbridled freedom is not what freedom truly concerns. There is a distinctive, Weak Arguments for Atheism traditional, conservative bent to Gregory’s thinking Gregory next pulls together the elements of his argu- here, with deep roots in the Stoic tradition. Freedom ment by persuasion. He has shown that becoming a must be exercise under the constraint of values and scientific physician does not commit one to becom- institutions worth preserving. These include religion ing an atheist, quite the opposite. Moreover, making based on conscience. atheism universal would result in societal calamity. Taken together the previous complementary consid- Religion is Natural to the Human erations lay bare the weak arguments for atheism. Mind Divested of that uncouth, metaphysical dress, under which they long lay concealed, the gloomy spec- Gregory then makes the point that we are naturally ulation of a few recluse men, they are now produced inclined to be religious: to the world, adorned with what passes among many Mankind may have their religious opinions dis- for wit and humour, and adapted to every capacity. figured by various superstitions: but still religion is So far as they contain any argument, their weakness natural to the human mind, and every attempt to has been often demonstrated (Gregory 1772, p. 66). eradicate it, will be found as impotent as it is wicked (Gregory 1772, p. 66). This idea retains its currency. Stempsey has re- Attacking Youth on the Weak Side cently argued, for example, that we are not only Gregory was a dedicated medical educator. He lent “Homo sapiens” but also “Homo religious” (Stempsey students his lecture notes and even, sometimes, mon- 2021). Evidence-based, scientific thinking inclines ey (McCullough 1998). He was concerned that young toward and not away from religion (Collins 2006). students might not have the maturity of thought that he has displayed in the above, complementary con- Socially Deleterious Consequences of siderations, and, as a consequence, become disre- Atheism spectful of religion. Recall that medical students in Scotland, then and now, start after secondary school. Gregory then invokes a time-honored argument form Gregory was but 19 years of age when he left Aber- in philosophical reasoning: Grant, for the sake of ar- deen to follow his father and older brother to study gument, an opponent’s position and then show that medicine in Edinburgh (McCullough 1998). this position has implications that anyone, including One method taken by the present patrons of infi- one’s opponent, should reject. delity to propagate their opinions is somewhat dan-

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gerous. With much assurance, they insinuate, that cians, admirable for their intellectual virtues, were all who avow their belief in natural or revealed reli- men of piety. So are persons who are admirable for gion, are either hypocrites or fools. This is attacking their moral virtues. youth on their weak side. A young man, of a liberal spirit, naturally disdains the idea of hypocrisy; and, The Study of Medicine does not Lead from an ill-judged pride, is afraid of whatever may subject him to so mean an imputation. Vanity, again, to Impiety is their most ruling passion, as they commonly dread Gregory next makes an argument based on the contempt above everything, and resent reflections on “works of nature.” This is known as the argument for the weakness and narrowness of their understand- the existence of the god of deism (there is a creator ing, more than any charge against their principles or and designer god who is the author of the patterns morals (Gregory 1772, pp. 66-67). of nature and has ordained those patterns to human Gregory was well aware that, with rare exceptions, and animal good). The evidence of transcendent de- young men (and now young women) do not enter sign is available to every scientific physician. their late teens or early twenties intellectually fully The study of medicine, of all others, should be the formed. Making the case for atheism when a student least suspected of leading to impiety. An intimate ac- does not have the intellectual tools on display in the quaintance with the works of Nature, raises the mind considerations above is impermissible pedagogi- to the most sublime conceptions of the Supreme cally. Moreover, should a medical student embrace Being, and at the same time dilates the heart with atheism, the origin of this change is not in scientific the most pleasing views of Providence. The difficul- medicine but in less-than-mature intellectual devel- ties that necessarily attend all deep enquiries into a opment and lack of clinical experience (see below). subject so disproportionate to the human faculties, In this passage, we add, Gregory is role-modeling for should not be suspected to surprize a physician, who, students the protection of the vulnerable that stu- in his practice, is often involved in perplexity, even dents were about to begin to learn in the wards of the Royal Infirmary of Edinburgh.

Useful and Amiable Men are Friends of Religion Gregory next offers a virtues-based consideration. To become a man of virtue, especially mastery of the professional virtues of tenderness and steadiness (en- gaging directly in the affective experience of patient in a self-disciplined way) and candor (the commitment to being open to evidence from whatever source), is at the heart of Lectures. Here Gregory makes the more general point that persons of virtue have social worth and earned moral standing for the rest of us. But I will venture to say, that men of the most enlarged, clear, and solid understandings, who have acted with the greatest spirit, dignity, and propriety, and who have been regarded as the most useful and amiable members of society, have never openly in- sulted, or insidiously attempted to ridicule the principles of religion; but, on the contrary, have been its best and warmest friends (Gregory 1772, pp. 67-68). These persons of virtue are not hostile to religion but its “best and warmest friends.” This complements his opening consideration. Scientific physi-

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in subjects exposed to the examination of his senses be aware of his own unhappy situation; yet it is bar- (Gregory 1772, p. 68). barous to deprive expiring nature of its last support, The complexity of clinical practice prepares phy- and to blast the only surviving comfort of those who sicians especially well for the task of gathering the have taken a last farewell of every sublunary pleasure. evidence for deism. But, if motives of humanity, and a regard to the peace and happiness of society cannot restrain a physician Clinical Experience Naturally Inclines from expressing sentiments destructive of religion or morals, it is vain to urge the decency of the profes- the Physician to Religion sion. The most favourable construction we can put Daily experience with the pain, distress, and suffer- on such conduct, is to suppose that it proceeds from ing of patients complements the results of the work an ungovernable levity, or a criminal vanity, that for- of nature with the results of tender and steady en- gets all the ties of morals, decency, and good manners gagement with patients. (Gregory 1772, pp. 69-70). There are, besides, some peculiar circumstances For the physician who fails to maintain compas- in the profession of a physician, which should natu- sionate, respectful silence about his or her atheism, rally dispose him to look beyond the present scene of Gregory reserves some of the strongest language in things, and engage his heart on the side of religion. Lectures. The final sentence is written in what Greg- He has many opportunities of seeing people, once ory himself would have described as “warm” terms. the gay and the happy, sunk in deep distress; some- Another way to put it is that in this sentence Gregory times devoted to a painful and lingering death; and is in high dudgeon, which his students and readers sometimes struggling with the tortures of a distract- would have immediately recognized as such. This ed mind. Such afflictive scenes, one should imagine, sentence can be restated in contemporary terms: No might soften any heart not dead to every feeling of physician should want to become despicable. humanity, and make it reverence that religion which alone can support the soul in the most complicat- CONCLUSION: MEDICINE IS A ed distresses; that religion, which teaches to enjoy life with cheerfulness, and to resign it with dignity SECULAR PROFESSION (Gregory 1772, pp. 68-69). The reader now has been introduced to Gregory’s ar- Religion based on freedom of conscience permits gument by persuasion against the view that becom- the believer to sustain meaning in his or her life, right ing a scientific physician commits one to atheism. No up to its final days. Gregory thus anticipates the one consideration is sufficient to make this case, but death with dignity movement in many countries in together, Gregory believes, his students and readers the last century and underscores the essential role should accept this conclusion. Gregory’s pioneering that religious belief can play for the maintenance of work on professional medical ethics from the eigh- dignity as one dies. teenth-century thus provides guidance for the management of the potentially contested boundary be- The Sensitive Physician Keeps his tween medicine and religion. The boundary between Atheism to Himself medicine and religion is not necessarily, but only potentially, contested. Gregory makes one final point to the atheist whom he The key to this conclusion is based on a theme has not been able to persuade: a physician committed that is implicit in the texts from his Lectures that to the compassionate care of patients, but is also an we have analyzed here. While Gregory did not use atheist, should remain systematically silent about his the word “secular” he put in place the concept of commitment. medicine as a secular profession that can guide the A physician, who has the misfortune to disbelieve Academy. The meaning of “secular” has two com- in a future state, will, if he have common good-na- ponents. First, medicine is a secular profession is ture, conceal his sentiments from those under his evidence-based. Evidence-based clinical reasoning charge, with as much care as he would preserve them draws of science, which creates intellectual tools that from the infection of a mortal disease. With a mind do not make – and need not make -- reference to di- unfeeling, or occupied in various pursuits, he may not vinity, transcendent reality, or sacred texts and prac-

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tices. The medical profession is therefore open to all, REFERENCES with no religious – or anti-religious – test. Second, in- asmuch as there is no requirement that being a phy- 1. Collins FS. The Language of God: A Scientist Presents Evi- dence for Belief. New York: The Free Press, 2006. sician means that one becomes an atheist. There is 2. Gregory J. Observations on the Duties and Qualifications of therefore no necessary hostility of medicine toward a Physician, and on the Method of Prosecuting Enquiries in religion and faith communities. Based on these two Philosophy. London: W. Strahan and T. Cadell, 1770. In Mc- components of the concept of medicine as secular, Cullough LB ed. John Gregory’s Writings on Medical Ethics and Philosophy of Medicine. Dordrecht: Springer, 1998; p. the boundary between medicine and religion need 93-159 not be contested. 3. Gregory J. Lectures on the Duties and Qualifications of a Physician. London: W. Strahan and T. Cadell, 1772. In Mc- Acknowledgements: None. Cullough LB ed. John Gregory’s Writings on Medical Ethics Conflict of Interest: None to declare. and Philosophy of Medicine. Dordrecht: Springer, 1998; p. 161-245 Contribution of Individual Authors: 4. McCullough LB. John Gregory and the Invention of Profes- Frank A. Chervenak and Laurence B. McCullough sional Medical Ethics and the Profession of Medicine. Dor- worked together to identify the topic of the paper drecht: Springer, 1998 and the historical resource, John Gregory’s Lectures on 5. McCullough LB, Coverdale JH, Chervenak FA. Professional Ethics in Obstetrics and Gynecology. New York and Cam- the Duties and Qualifications of a Physician (1772), upon bridge: Cambridge University Press, 2020. which the paper draws. They also worked together 6. Stempsey WE. Homo religious: the soul of bioethics. J Med on the philosophical and clinical analysis of the pas- Philos 2021; 46: 238-253. sages from Lectures and the preparation of the paper 7. U.S. Public Broadcasting System. Question of God: Francis through its successive drafts. Collins. 2004. Available at The Question of God . Other Voic- es . Francis Collins | PBS, accessed May 5, 2021.

SAŽETAK Cilj ovog rada je osloniti se na stavove Johna Gregorya (1724-1773) o profesionalnoj etici u medicini kako bi liječnicima pružili smjernice za odgovorno upravljanje potencijalno spornim razgraničenjem između medicine i religije. Ovaj rad donosi filozofsku i kliničku interpretaciju Gregoryeve metode argumenta uvjeravanjem: predstavljanje komplementarnih razmatranja koja zajedno pozivaju na slaganje. Kumulativni rezultat ovog argumenta uvjeravanjem je da znanstvena praksa medicine, temeljena na dokazima, nema potrebu za spornom granicom između medicine i religije. Gregoryevo naslijeđe nama je koncept sekularne medicinske struke, u dva smisla. Kao znanost, medicina se oslanja na dokaze, a ne na božansko, nadiskustvenu stvarnost ili svete spise i prakse. Medicina temeljena na dokazima nema potrebu za antagonizmom prema religiji i vjerskim zajednicama.

Ključne riječi: medicina – profesionalna etika – Gregory-ev metoda – interpretacije – EBM (medicina uteme- ljena na dokazima)

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